CBT+ Training Initiative in Washington State Community Mental Health: An Evaluation of Child Clinical Outcomes

The Washington State CBT+  Initiative offers a flexible training and consultation approach for community mental health providers in evidence-based practices for four child mental health targets: cognitive behavioral therapy for depression, anxiety, trauma, and behavioral difficulties. As part of consultation, clinicians used an online system to track delivery of treatment components and clinical outcomes using standardized symptom measures. The current study used these clinician-input data to examine symptom change for children using paired sample t-tests. Additionally, we explored if time elapsed or number of sessions between measurements related to symptom change using simple linear regression. Children had significant symptom reduction across all four targets. For most measures, children did not show greater improvements with increased length of time or increased number of sessions between assessment measures. Findings suggest that children treated by a CBT+  trained clinician may demonstrate symptom reduction for their primary clinical problem. Findings add to support for flexible training approaches for community mental health clinicians.

A qualitative study of mental health problems among children living in New Delhi slums

Children living in urban slums in India are exposed to chronic stressors that increase their risk of developing mental disorders, but they remain a neglected group. Effective mental health interventions are needed; however, it is necessary to understand how mental health symptoms and needs are perceived and prioritized locally to tailor interventions for this population. We used an existing rapid ethnographic assessment approach to identify mental health problems from the perspective of children living in Indian slums, including local descriptions, perceived causes, impact, and coping behavior. Local Hindi-speaking interviewers conducted 77 free-list interviews and 33 key informant interviews with children and adults (N = 107) from two slums in New Delhi. Results identified a range of internalizing and externalizing symptoms consistent with depression, anxiety, and conduct problems in children. Findings included both common cross-cultural experiences and symptoms as well as uniquely described symptoms (e.g., "madness or anger," "pain in the heart and mind") not typically included on western standardized measures of psychopathology. Mental health problems appeared to be highly interconnected, with experiences such as harassment and fighting often described as both causes and impacts of mental health symptoms in children. Community perspectives indicated that even in the face of several unmet basic needs, mental health problems were important to the community and counseling interventions were likely to be acceptable. We discuss implications for adapting mental health interventions and assessing their effectiveness to reduce the burden of mental illness among children living in urban slums in India.

Middle managers' role in implementing evidence-based practices in healthcare: a systematic review

BACKGROUND

Middle managers are in a unique position to promote the implementation of evidence-based practices (EBPs) in healthcare organizations, yet knowledge of middle managers' role in implementation and determinants (e.g., individual-, organizational-, and system-level factors) which influence their role remains fractured, spanning decades and disciplines. To synthesize understanding, we undertook a systematic review of studies of middle managers' role in healthcare EBP implementation and determinants of that role.

METHODS

We searched MEDLINE/PubMed and Business Source Complete (Ebsco) for literature on middle managers' role in healthcare EBP implementation and its determinants. We abstracted data from records that met inclusion criteria (i.e., written in English, peer-reviewed, and reporting either a protocol or results of an empirical study) into a matrix for analysis. We summarized categorical variables using descriptive statistics. To analyze qualitative data, we used a priori codes and then allowed additional themes to emerge.

RESULTS

One hundred five records, spanning across several countries and healthcare settings and relating to a range of EBPs, met our inclusion criteria. Studies of middle managers' role in healthcare EBP implementation and its determinants substantially increased from 1996 to 2015. Results from included studies suggest that middle managers shape implementation climate in addition to fulfilling the four roles hypothesized in extant theory of middle managers' role in implementation. However, extant studies offered little understanding of determinants of middle managers' role.

CONCLUSIONS

Our findings suggest that middle managers may play an important role in facilitating EBP implementation. Included studies offered little understanding regarding the relative importance of various roles, potential moderators of the relationship between middle managers' roles and EBP implementation, or determinants of middle managers' role in EBP implementation. Future studies should seek to understand determinants and moderators of middle managers' role. Clearer understanding may facilitate the translation of evidence into practice.

Trends of Colorectal Cancer Incidence in Thailand by Age, Gender, and Region

Background: Colorectal cancer (CRC) is the third most common cancer in the world. While CRC incidence has decreased in many western countries over the last decades, largely thanks to screening, it is increasing in low and middle-income countries, including Thailand. However, it is unclear if these increases are consistent across different regions, gender and age groups. Aim: To understand the age-, gender- and region-specific temporal variation in CRC incidence in Thailand since the 1990s. Methods: We analyzed CRC incidence data from the Thailand National Cancer Network (TCIN) cancer registries, which include Chiang Mai (1990-2012), Lampang (1993-2014), Lopburi (2000-2014), Khon Kaen (1990-2014) and Songkhla (1990-2014) cancer registries. Trends in age-adjusted incidence (measured by annual percentage change (APC)) were assessed using Joinpoint regression. Trends by birth-year and calendar-year were assessed using age-period-cohort models. All analyses were done by region, gender, and age group (30-49, 50-84, 30-84). Results: CRC incidence has been increasing significantly in all regions, gender, and age groups; Overall, the APC was 3.82 for men and 3.84 for women (Chiang Mai, 4.34 for men & 3.26 for women; Khon Kaen, 2.69 for men & 3.68 for women; Lampang, 2.13 for men & 3.37 for women; Lopburi, 5.31 for men & 4.67 for women; Songkhla, 4.67 for men & 4.32 for women). The increase in incidence was higher for ages 50-84 (APC = 3.99 for men & 4.04 for women) compared with ages 30-49 (APC=2.97 for men & 3.09 for women). Test of parallelism suggests that increases are consistent between gender (P-value=0.97). The age-period-cohort analysis suggests that both calendar-year and birth-year are strongly correlated with CRC incidence trends, with a stronger relationship with birth-year than calendar-year for both genders. Conclusion: In contrast to western countries such as the US, CRC incidence is increasing across all age groups in Thailand, with faster increase in older ages. This highlights the needs for establishing population-wide screening programs to reduce the burden and stop the rise of CRC in Thailand and low-middle income countries.

Supervision in Community Mental Health: Understanding Intensity of EBT Focus

The goal of the present study was to examine clinician, supervisor, and organizational factors that are associated with the intensity of evidence-based treatment (EBT) focus in workplace-based clinical supervision of a specific EBT, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Supervisors (n = 56) and clinicians (n = 207) from mental health organizations across Washington State completed online self-report questionnaires. Multilevel modeling (MLM) analyses were used to examine the relative influence of nested clinician and supervisor factors on the intensity of EBT focus in supervision. We found that 33% of the variance in clinician report of EBT supervision intensity clustered at the supervisor level and implementation climate was the only significant factor associated with EBT supervision intensity. While individual clinician and supervisor factors may play a role in EBT coverage in supervision, our results suggest that an implementation climate that supports EBT may be the most critical factor for improving intensity of EBT coverage. Thus, implementation efforts that address the extent to which EBTs are expected, rewarded, and supported within an organization may be needed to support greater coverage of EBT during workplace-based supervision.

They're Doing What? A Brief Paper on Service Use and Attitudes in ASD Community-Based Agencies

This brief paper examined the community services delivered to youth with autism spectrum disorder (ASD) in a Southern Californian city as a way to better understand ASD service provision and service attitudes. Specific goals of the study were to identify the services being delivered within the area, and how the use, perceived evidence and value attached to these services mapped onto recent systematic ASD service reviews. Forty-six providers completed the ASD Strategies and Interventions Survey (ASD-SIS), which consisted of 21 treatment strategies and 22 interventions packages commonly used with children with ASD. Participants: 1) indicated each treatment strategy and intervention package they use; and 2) rated the perceived evidence and value of each treatment strategy and intervention package they endorsed using. Results demonstrated that a variety of treatment strategies and intervention packages, both with and without an established evidence base, were reportedly being delivered to youth with ASD through community-based agencies. Additionally, a large number of providers reported not knowing the evidence of many treatment strategies and intervention packages. Finally, although no relationship was found between evidence base and use, perceived evidence, and value for treatment strategies, providers reported significantly higher use, perceived evidence and value for established intervention packages. Results demonstrate the need to more effectively disseminate strategies that can support providers in selecting services to deliver to youth with ASD, and underscore the need to better understand the community service landscape on a larger scale.

Community-Academic Partnership Participation

Community-academic partnerships (CAPs) improve the research process, outcomes, and yield benefits for the community and researchers. This exploratory study examined factors important in community stakeholders' decision to participate in CAPs. Autism spectrum disorder (ASD) community stakeholders, previously contacted to participate in a CAP (n = 18), completed the 15-item Decision to Participate Questionnaire (DPQ). The DPQ assessed reasons for participating or declining participation in the ASD CAP. CAP participants rated networking with other providers, fit of collaboration with agency philosophy, and opportunity for future training/consultations as factors more important in their decision to participate in the ASD CAP than nonparticipants. Nonparticipants reported the number of requests to participate in research as more important in their decision to decline participation than participants. Findings reveal important factors in community stakeholders' decision to participate in CAPs that may provide guidance on increasing community engagement in CAPs and help close the science-to-service gap.

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science : Seattle, WA, USA. 24-26 September 2015

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Cara Lewis, Doyanne Darnell, Suzanne Kerns, Maria Monroe-DeVita, Sara J. Landes, Aaron R. Lyon, Cameo Stanick, Shannon Dorsey, Jill Locke, Brigid Marriott, Ajeng Puspitasari, Caitlin Dorsey, Karin Hendricks, Andria Pierson, Phil Fizur, Katherine A. Comtois

A1: A behavioral economic perspective on adoption, implementation, and sustainment of evidence-based interventions

Lawrence A. Palinkas

A2: Towards making scale up of evidence-based practices in child welfare systems more efficient and affordable

Patricia Chamberlain

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A5: Efficient synthesis: Using qualitative comparative analysis and the Consolidated Framework for Implementation Research across diverse studies

Laura J. Damschroder, Julie C. Lowery

A6: Establishing a veterans engagement group to empower patients and inform Veterans Affairs (VA) health services research

Sarah S. Ono, Kathleen F. Carlson, Erika K. Cottrell, Maya E. O’Neil, Travis L. Lovejoy

A7: Building patient-practitioner partnerships in community oncology settings to implement behavioral interventions for anxious and depressed cancer survivors

Joanna J. Arch, Jill L. Mitchell

A8: Tailoring a Cognitive Behavioral Therapy implementation protocol using mixed methods, conjoint analysis, and implementation teams

Cara C. Lewis, Brigid R. Marriott, Kelli Scott

A9: Wraparound Structured Assessment and Review (WrapSTAR): An efficient, yet comprehensive approach to Wraparound implementation evaluation

Jennifer Schurer Coldiron, Eric J. Bruns, Alyssa N. Hook

A10: Improving the efficiency of standardized patient assessment of clinician fidelity: A comparison of automated actor-based and manual clinician-based ratings

Benjamin C. Graham, Katelin Jordan

A11: Measuring fidelity on the cheap

Rochelle F. Hanson, Angela Moreland, Benjamin E. Saunders, Heidi S. Resnick

A12: Leveraging routine clinical materials to assess fidelity to an evidence-based psychotherapy

Shannon Wiltsey Stirman, Cassidy A. Gutner, Jennifer Gamarra, Dawne Vogt, Michael Suvak, Jennifer Schuster Wachen, Katherine Dondanville, Jeffrey S. Yarvis, Jim Mintz, Alan L. Peterson, Elisa V. Borah, Brett T. Litz, Alma Molino, Stacey Young McCaughanPatricia A. Resick

A13: The video vignette survey: An efficient process for gathering diverse community opinions to inform an intervention

Nancy Pandhi, Nora Jacobson, Neftali Serrano, Armando Hernandez, Elizabeth Zeidler- Schreiter, Natalie Wietfeldt, Zaher Karp

A14: Using integrated administrative data to evaluate implementation of a behavioral health and trauma screening for children and youth in foster care

Michael D. Pullmann, Barbara Lucenko, Bridget Pavelle, Jacqueline A. Uomoto, Andrea Negrete, Molly Cevasco, Suzanne E. U. Kerns

A15: Intermediary organizations as a vehicle to promote efficiency and speed of implementation

Robert P. Franks, Christopher Bory

A16: Applying the Consolidated Framework for Implementation Research constructs directly to qualitative data: The power of implementation science in action

Edward J. Miech, Teresa M. Damush

A17: Efficient and effective scaling-up, screening, brief interventions, and referrals to treatment (SBIRT) training: a snowball implementation model

Jason Satterfield, Derek Satre, Maria Wamsley, Patrick Yuan, Patricia O’Sullivan

A18: Matching models of implementation to system needs and capacities: addressing the human factor

Helen Best, Susan Velasquez

A19: Agency characteristics that facilitate efficient and successful implementation efforts

Miya Barnett, Lauren Brookman-Frazee, Jennifer Regan, Nicole Stadnick, Alison Hamilton, Anna Lau

A20: Rapid assessment process: Application to the Prevention and Early Intervention transformation in Los Angeles County

Jennifer Regan, Alison Hamilton, Nicole Stadnick, Miya Barnett, Anna Lau, Lauren Brookman-Frazee

A21: The development of the Evidence-Based Practice-Concordant Care Assessment: An assessment tool to examine treatment strategies across practices

Nicole Stadnick, Anna Lau, Miya Barnett, Jennifer Regan, Scott Roesch, Lauren Brookman-Frazee

A22: Refining a compilation of discrete implementation strategies and determining their importance and feasibility

Byron J. Powell, Thomas J. Waltz, Matthew J. Chinman, Laura Damschroder, Jeffrey L. Smith, Monica M. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A23: Structuring complex recommendations: Methods and general findings

Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica J. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A24: Implementing prolonged exposure for post-traumatic stress disorder in the Department of Veterans Affairs: Expert recommendations from the Expert Recommendations for Implementing Change (ERIC) project

Monica M. Matthieu, Craig S. Rosen, Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Enola K. Proctor, JoAnn E. Kirchner

A25: When readiness is a luxury: Co-designing a risk assessment and quality assurance process with violence prevention frontline workers in Seattle, WA

Sarah C. Walker, Asia S. Bishop, Mariko Lockhart

A26: Implementation potential of structured recidivism risk assessments with justice- involved veterans: Qualitative perspectives from providers

Allison L. Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, Daniel M. Blonigen

A27: Developing empirically informed readiness measures for providers and agencies for the Family Check-Up using a mixed methods approach

Anne M. Mauricio, Thomas D. Dishion, Jenna Rudo-Stern, Justin D. Smith

A28: Pebbles, rocks, and boulders: The implementation of a school-based social engagement intervention for children with autism

Jill Locke, Courtney Benjamin Wolk, Colleen Harker, Anne Olsen, Travis Shingledecker, Frances Barg, David Mandell, Rinad S. Beidas

A29: Problem Solving Teletherapy (PST.Net): A stakeholder analysis examining the feasibility and acceptability of teletherapy in community based aging services

Marissa C. Hansen, Maria P. Aranda, Isabel Torres-Vigil

A30: A case of collaborative intervention design eventuating in behavior therapy sustainment and diffusion

Bryan Hartzler

A31: Implementation of suicide risk prevention in an integrated delivery system: Mental health specialty services

Bradley Steinfeld, Tory Gildred, Zandrea Harlin, Fredric Shephard

A32: Implementation team, checklist, evaluation, and feedback (ICED): A step-by-step approach to Dialectical Behavior Therapy program implementation

Matthew S. Ditty, Andrea Doyle, John A. Bickel III, Katharine Cristaudo

A33: The challenges in implementing muliple evidence-based practices in a community mental health setting

Dan Fox, Sonia Combs

A34: Using electronic health record technology to promote and support evidence-based practice assessment and treatment intervention

David H. Lischner

A35: Are existing frameworks adequate for measuring implementation outcomes? Results from a new simulation methodology

Richard A. Van Dorn, Stephen J. Tueller, Jesse M. Hinde, Georgia T. Karuntzos

A36: Taking global local: Evaluating training of Washington State clinicians in a modularized cogntive behavioral therapy approach designed for low-resource settings

Maria Monroe-DeVita, Roselyn Peterson, Doyanne Darnell, Lucy Berliner, Shannon Dorsey, Laura K. Murray

A37: Attitudes toward evidence-based practices across therapeutic orientations

Yevgeny Botanov, Beverly Kikuta, Tianying Chen, Marivi Navarro-Haro, Anthony DuBose, Kathryn E. Korslund, Marsha M. Linehan

A38: Predicting the use of an evidence-based intervention for autism in birth-to-three programs

Colleen M. Harker, Elizabeth A. Karp, Sarah R. Edmunds, Lisa V. Ibañez, Wendy L. Stone

A39: Supervision practices and improved fidelity across evidence-based practices: A literature review

Mimi Choy-Brown

A40: Beyond symptom tracking: clinician perceptions of a hybrid measurement feedback system for monitoring treatment fidelity and client progress

Jack H. Andrews, Benjamin D. Johnides, Estee M. Hausman, Kristin M. Hawley

A41: A guideline decision support tool: From creation to implementation

Beth Prusaczyk, Alex Ramsey, Ana Baumann, Graham Colditz, Enola K. Proctor

A42: Dabblers, bedazzlers, or total makeovers: Clinician modification of a common elements cognitive behavioral therapy approach

Rosemary D. Meza, Shannon Dorsey, Shannon Wiltsey-Stirman, Georganna Sedlar, Leah Lucid

A43: Characterization of context and its role in implementation: The impact of structure, infrastructure, and metastructure

Caitlin Dorsey, Brigid Marriott, Nelson Zounlome, Cara Lewis

A44: Effects of consultation method on implementation of cognitive processing therapy for post-traumatic stress disorder

Cassidy A. Gutner, Candice M. Monson, Norman Shields, Marta Mastlej, Meredith SH Landy, Jeanine Lane, Shannon Wiltsey Stirman

A45: Cross-validation of the Implementation Leadership Scale factor structure in child welfare service organizations

Natalie K. Finn, Elisa M. Torres, Mark. G. Ehrhart, Gregory A. Aarons

A46: Sustainability of integrated smoking cessation care in Veterans Affairs posttraumatic stress disorder clinics: A qualitative analysis of focus group data from learning collaborative participants

Carol A. Malte, Aline Lott, Andrew J. Saxon

A47: Key characteristics of effective mental health trainers: The creation of the Measure of Effective Attributes of Trainers (MEAT)

Meredith Boyd, Kelli Scott, Cara C. Lewis

A48: Coaching to improve teacher implementation of evidence-based practices (EBPs)

Jennifer D. Pierce

A49: Factors influencing the implementation of peer-led health promotion programs targeting seniors: A literature review

Agathe Lorthios-Guilledroit, Lucie Richard, Johanne Filiatrault

A50: Developing treatment fidelity rating systems for psychotherapy research: Recommendations and lessons learned

Kevin Hallgren, Shirley Crotwell, Rosa Muñoz, Becky Gius, Benjamin Ladd, Barbara McCrady, Elizabeth Epstein

A51: Rapid translation of alcohol prevention science

John D. Clapp, Danielle E. Ruderman

A52: Factors implicated in successful implementation: evidence to inform improved implementation from high and low-income countries

Melanie Barwick, Raluca Barac, Stanley Zlotkin, Laila Salim, Marnie

Davidson

A53: Tracking implementation strategies prospectively: A practical approach

Alicia C. Bunger, Byron J. Powell, Hillary A. Robertson

A54: Trained but not implementing: the need for effective implementation planning tools

Christopher Botsko

A55: Evidence, context, and facilitation variables related to implementation of Dialectical Behavior Therapy: Qualitative results from a mixed methods inquiry in the Department of Veterans Affairs

Sara J. Landes, Brandy N. Smith, Allison L. Rodriguez, Lindsay R. Trent, Monica M. Matthieu

A56: Learning from implementation as usual in children’s mental health

Byron J. Powell, Enola K. Proctor

A57: Rates and predictors of implementation after Dialectical Behavior Therapy Intensive Training

Melanie S. Harned, Marivi Navarro-Haro, Kathryn E. Korslund, Tianying Chen, Anthony DuBose, André Ivanoff, Marsha M. Linehan

A58: Socio-contextual determinants of research evidence use in public-youth systems of care

Antonio R. Garcia, Minseop Kim, Lawrence A. Palinkas, Lonnie Snowden, John Landsverk

A59: Community resource mapping to integrate evidence-based depression treatment in primary care in Brazil: A pilot project

Annika C. Sweetland, Maria Jose Fernandes, Edilson Santos, Cristiane Duarte, Afrânio Kritski, Noa Krawczyk, Caitlin Nelligan, Milton L. Wainberg

A60: The use of concept mapping to efficiently identify determinants of implementation in the National Institute of Health--President’s Emergent Plan for AIDS Relief Prevention of Mother to Child HIV Transmission Implementation Science Alliance

Gregory A. Aarons, David H. Sommerfeld, Benjamin Chi, Echezona Ezeanolue, Rachel Sturke, Lydia Kline, Laura Guay, George Siberry

A61: Longitudinal remote consultation for implementing collaborative care for depression

Ian M. Bennett, Rinad Beidas, Rachel Gold, Johnny Mao, Diane Powers, Mindy Vredevoogd, Jurgen Unutzer

A62: Integrating a peer coach model to support program implementation and ensure long- term sustainability of the Incredible Years in community-based settings

Jennifer Schroeder, Lane Volpe, Julie Steffen

A63: Efficient sustainability: Existing community based supervisors as evidence-based treatment supports

Shannon Dorsey, Michael D Pullmann, Suzanne E. U. Kerns, Nathaniel Jungbluth, Lucy Berliner, Kelly Thompson, Eliza Segell

A64: Establishment of a national practice-based implementation network to accelerate adoption of evidence-based and best practices

Pearl McGee-Vincent, Nancy Liu, Robyn Walser, Jennifer Runnals, R. Keith Shaw, Sara J. Landes, Craig Rosen, Janet Schmidt, Patrick Calhoun

A65: Facilitation as a mechanism of implementation in a practice-based implementation network: Improving care in a Department of Veterans Affairs post-traumatic stress disorder outpatient clinic

Ruth L. Varkovitzky, Sara J. Landes

A66: The ACT SMART Toolkit: An implementation strategy for community-based organizations providing services to children with autism spectrum disorder

Amy Drahota, Jonathan I. Martinez, Brigitte Brikho, Rosemary Meza, Aubyn C. Stahmer, Gregory A. Aarons

A67: Supporting Policy In Health with Research: An intervention trial (SPIRIT) - protocol and early findings

Anna Williamson

A68: From evidence based practice initiatives to infrastructure: Lessons learned from a public behavioral health system’s efforts to promote evidence based practices

Ronnie M. Rubin, Byron J. Powell, Matthew O. Hurford, Shawna L. Weaver, Rinad S. Beidas, David S. Mandell, Arthur C. Evans

A69: Applying the policy ecology model to Philadelphia’s behavioral health transformation efforts

Byron J. Powell, Rinad S. Beidas, Ronnie M. Rubin, Rebecca E. Stewart, Courtney Benjamin Wolk, Samantha L. Matlin, Shawna Weaver, Matthew O. Hurford, Arthur C. Evans, Trevor R. Hadley, David S. Mandell

A70: A model for providing methodological expertise to advance dissemination and implementation of health discoveries in Clinical and Translational Science Award institutions

Donald R. Gerke, Beth Prusaczyk, Ana Baumann, Ericka M. Lewis, Enola K. Proctor

A71: Establishing a research agenda for the Triple P Implementation Framework

Jenna McWilliam, Jacquie Brown, Michelle Tucker

A72: Cheap and fast, but what is “best?”: Examining implementation outcomes across sites in a state-wide scaled-up evidence-based walking program, Walk With Ease

Kathleen P Conte

A73: Measurement feedback systems in mental health: Initial review of capabilities and characteristics

Aaron R. Lyon, Meredith Boyd, Abigail Melvin, Cara C. Lewis, Freda Liu, Nathaniel Jungbluth

A74: A qualitative investigation of case managers’ attitudes toward implementation of a measurement feedback system in a public mental health system for youth

Amelia Kotte, Kaitlin A. Hill, Albert C. Mah, Priya A. Korathu-Larson, Janelle R. Au, Sonia Izmirian, Scott Keir, Brad J. Nakamura, Charmaine K. Higa-McMillan

A75: Multiple pathways to sustainability: Using Qualitative Comparative Analysis to uncover the necessary and sufficient conditions for successful community-based implementation

Brittany Rhoades Cooper, Angie Funaiole, Eleanor Dizon

A76: Prescribers’ perspectives on opioids and benzodiazepines and medication alerts to reduce co-prescribing of these medications

Eric J. Hawkins, Carol A. Malte, Hildi J. Hagedorn, Douglas Berger, Anissa Frank, Aline Lott, Carol E. Achtmeyer, Anthony J. Mariano, Andrew J. Saxon

A77: Adaptation of Coordinated Anxiety Learning and Management for comorbid anxiety and substance use disorders: Delivery of evidence-based treatment for anxiety in addictions treatment centers

Kate Wolitzky-Taylor, Richard Rawson, Richard Ries, Peter Roy-Byrne, Michelle Craske

A78: Opportunities and challenges of measuring program implementation with online surveys

Dena Simmons, Catalina Torrente, Lori Nathanson, Grace Carroll

A79: Observational assessment of fidelity to a family-centered prevention program: Effectiveness and efficiency

Justin D. Smith, Kimbree Brown, Karina Ramos, Nicole Thornton, Thomas J. Dishion, Elizabeth A. Stormshak, Daniel S. Shaw, Melvin N. Wilson

A80: Strategies and challenges in housing first fidelity: A multistate qualitative analysis

Mimi Choy-Brown, Emmy Tiderington, Bikki Tran Smith, Deborah K. Padgett

A81: Procurement and contracting as an implementation strategy: Getting To Outcomes® contracting

Ronnie M. Rubin, Marilyn L. Ray, Abraham Wandersman, Andrea Lamont, Gordon Hannah, Kassandra A. Alia, Matthew O. Hurford, Arthur C. Evans

A82: Web-based feedback to aid successful implementation: The interactive Stages of Implementation Completion (SIC)^TM tool

Lisa Saldana, Holle Schaper, Mark Campbell, Patricia Chamberlain

A83: Efficient methodologies for monitoring fidelity in routine implementation: Lessons from the Allentown Social Emotional Learning Initiative

Valerie B. Shapiro, B.K. Elizabeth Kim, Jennifer L. Fleming, Paul A. LeBuffe

A84: The Society for Implementation Research Collaboration (SIRC) implementation development workshop: Results from a new methodology for enhancing implementation science proposals

Sara J. Landes, Cara C. Lewis, Allison L. Rodriguez, Brigid R. Marriott, Katherine Anne Comtois

A85: An update on the Society for Implementation Research Collaboration (SIRC) Instrument Review Project

Prevalence of bacterial vaginosis among young women in low-income populations of coastal Peru

The goal of this study was to determine the prevalence of bacterial vaginosis (BV) in Peruvian women from socioeconomically deprived populations and to determine the association between BV and risk factors for sexually transmitted diseases (STDs). Women were administered an epidemiologic survey to determine sexual risk behaviour and they provided biological samples to test for BV and STDs. The prevalence of BV was high (27%) and was significantly associated with having a bacterial STD or trichomoniasis. Age, marital status, and a history of sex work, but not of sexual experience, frequency of intercourse, and unprotected intercourse, were associated with BV. As BV may be a marker for STDs, screening for STDs should be performed in individuals with BV to promote early detection and treatment of co-infecting sexually transmitted pathogens.

Reservoir interactions and disease emergence

Animal populations act as reservoirs for emerging diseases. In order for transmission to be self-sustaining, a pathogen must have a basic reproduction number R0>1. Following a founding transmission event from an animal reservoir to humans, a pathogen has not yet adapted to its new environment and is likely to have an R0<1. However, subsequent evolution may rescue the pathogen from extinction in its new host. Recent applications of branching process theory investigate how the emergence of a novel pathogen is influenced by the number and rates of intermediate evolutionary steps. In addition, repeated contacts between human and reservoir populations may promote pathogen emergence. This article extends a stepping-stone model of pathogen evolution to include reservoir interactions. We demonstrate that the probability of a founding event culminating in an emerged pathogen can be significantly influenced by ongoing reservoir interactions. While infrequent reservoir interactions do not change the probability of disease emergence, moderately frequent interactions can promote emergence by facilitating adaptation to humans. Frequent reservoir interactions promote emergence even with minimal adaptation to humans. Thus, these results warn against perpetuated interaction between humans and animal reservoirs, as occurs when there are ecological or environmental changes that bring humans into more frequent contact with animal reservoirs.

Acute Helicobacter pylori infection is followed by an increase in diarrheal disease among Peruvian children

BACKGROUND

Cohort and case-crossover studies were conducted to evaluate whether new Helicobacter pylori infections are followed by increased diarrhea.

METHODS

Participants were 6-month-old to 12-year-old shantytown residents living near Lima, Peru. Baseline data were collected from community households. Health interviews were completed daily, and sera, drawn every 4 months, were tested for H pylori immunoglobulin G. Diarrhea rates among newly H pylori-infected (seroconverting) children were compared with rates among persistently uninfected and infected children using cohort and case-crossover analyses.

RESULTS

Sera were obtained from 345 children from January 1, 1995, through September 1, 1997. H pylori incidence was 12% per year (36 H pylori infections in 109 866 seronegative days). In adjusted cohort analyses, seroconverters had more diarrhea days (rate ratio: 2.0; 95% confidence interval: 1.6-2.4), episodes, and sick days in the year after infection than did uninfected children; and more diarrhea days and sick days than did persistently infected children. This effect was strongest in the first 2 months. Case-crossover analyses supported these findings.

CONCLUSION

Preventing H pylori infection may help reduce pediatric diarrheal disease.

Posttreatment follow-up of Helicobacter pylori infection using a stool antigen immunoassay

The Helicobacter pylori stool antigen enzyme immunoassay (HpSA) was evaluated during posttreatment follow-up of patients in a country with a very high prevalence of H. pylori infection. From among 273 dyspeptic individuals (18 to 55 years) initially recruited from a shantytown in Lima, Peru, 238 participants who met the inclusion criteria and were suspected to be H. pylori positive based on (14)C urea breath test (UBT) results underwent endoscopy. Participants with endoscopy-proven infections received standard eradication therapy and were monitored by UBT and HpSA at 1 month following treatment and at 3-month intervals for 9 months posttreatment. A second endoscopy was performed if UBT results showed evidence of treatment failure or H. pylori recurrence. Biopsy results were considered the "gold standard" in all analyses. Among patients who underwent endoscopy, HpSA had a pretreatment sensitivity of 93%. Two-hundred thirty patients completed the treatment regimen, of whom 201 (93%) were considered to have had successful treatment outcomes based on a negative follow-up UBT. Thirty-two patients with UBT-defined treatment failures or H. pylori recurrences at any point during the 9-month follow-up underwent a second endoscopy. In the posttreatment setting, HpSA had an overall sensitivity of 73% and a specificity of 67%. Agreement between UBT and HpSA diminished throughout the follow-up. Among 14 participants in whom HpSA remained positive at 1 month following treatment despite UBT evidence of treatment success, 12 (86%) became HpSA negative within 3 months posttreatment. Although this study confirmed the validity of the HpSA in the initial assessment of dyspeptic patients, the test demonstrated a reduced overall accuracy in the detection of treatment failures and H. pylori recurrences during 9 months of posttreatment follow-up. Furthermore, in some patients it may take up to 3 months after successful eradication for antigen shedding to diminish to levels within the negative HpSA range.

Two-year study of the protective efficacy of the oral whole cell plus recombinant B subunit cholera vaccine in Peru

The protective efficacy of an oral inactivated whole cell Vibrio cholerae plus recombinant B subunit cholera vaccine was determined against El Tor cholera among Peruvian children and adults (2-65 years old) in a randomized, double-blind manner. Study subjects received 2 doses of vaccine or placebo 2 weeks apart, followed by a booster dose 10 months later. Surveillance for cholera was performed actively, with 2 visits per week to each household, and passively, at a local hospital. Stool samples were collected during diarrhea episodes and were cultured for V. cholerae. A total of 17,799 persons received 2 doses of vaccine or placebo, and 14,997 of these persons received the booster dose. After 2 doses (first surveillance period), V. cholerae biotype O1 was isolated from 17 vaccinees and 16 placebo recipients, demonstrating vaccine efficacy (VE) of -4%. After 3 doses (second surveillance period), V. cholerae O1 was isolated from 13 vaccinees and 32 placebo recipients, demonstrating VE of 61% (95% confidence interval ¿CI, 28%-79%). In the second surveillance period, the VE for illness requiring hospitalization was 82% (95% CI, 27%-96%). VE was also higher for persons >15 years old (VE, 72%; 95% CI, 28%-89%).

A placebo-controlled trial of Lactobacillus GG to prevent diarrhea in undernourished Peruvian children

OBJECTIVE

Lactobacillus GG (L-GG), an acid- and bile-resistant strain that colonizes the intestinal mucosa, has been used to manage diarrhea in children. Our objective was to evaluate the prophylactic use of L-GG to prevent diarrhea in children at high risk from a developing country in a randomized, placebo-controlled trial.

STUDY DESIGN

Two hundred four undernourished children 6 to 24 months old from an indigent peri-urban Peruvian town received either L-GG or placebo in flavored gelatin once daily, 6 days a week, for 15 months. Episodes of diarrhea were documented by daily home visits, and diagnostic studies were done in a subset of cases. Recovery of L-GG in stool from subjects and from family contacts was examined.

RESULTS

Subjects in the L-GG group had significantly fewer episodes of diarrhea (5.21 episodes diarrhea/child/year ['ecy'] L-GG group, 6. 02 ecy placebo group; P =.028). The decreased incidence of diarrhea in the L-GG group was greatest in the 18- to 29-month age group (P =. 004) and was largely limited to nonbreastfed children (Breastfed: 6. 59 ecy L-GG, 6.32 ecy placebo, P =.7; Nonbreastfed: 4.69 ecy L-GG, 5. 86 ecy placebo, P =.005). The duration of diarrhea episodes and the causes of diarrhea were similar in both groups, except adenovirus was more common in the placebo group.

CONCLUSION

L-GG supplementation may be useful as a prophylactic measure to control diarrhea in undernourished children at increased risk, especially nonbreastfed children in the toddler age group.

Vibrio furnissii isolated from humans in Peru: a possible human pathogen?

During a cholera surveillance programme, Vibrio furnissii was isolated in late January and early February 1994 from stool samples collected from 14 persons of whom six had diarrhoea. The remaining eight persons were healthy family members or neighbours to cholera cases. No common source of infection was found. Strains isolated from stool samples each showed typical biochemical reactions of V. furnissii including gas production. Each isolate, except one, agglutinated O-antisera yielding a total of eight different serotypes. Most isolates were sensitive to 10 antibiotics tested, except to ampicillin and the vibriostatic agent O/129 (10 micrograms). Eight of 14 (57%) strains carried plasmids in the size range 2.6-88 kb, however, no correlation was found between antibiotic susceptibility patterns and plasmid content. Altogether, seven closely related HindIII ribotypes were observed among the 14 V. furnissii isolates studied. V. furnissii strains isolated from family members and other persons living close together often showed different ribotypes suggesting that the isolation was not associated with neighbourhood. Serotyping, plasmid profiling and ribotyping revealed a high strain diversity within V. furnissii, however, the importance of V. furnissii as an enteric pathogen remains to be elucidated.

Evaluation of a bivalent (CVD 103-HgR/CVD 111) live oral cholera vaccine in adult volunteers from the United States and Peru

To provide optimum protection against classical and El Tor biotypes of Vibrio cholerae O1, a single-dose, oral cholera vaccine was developed by combining two live, attenuated vaccine strains, CVD 103-HgR (classical, Inaba) and CVD 111 (El Tor, Ogawa). The vaccines were formulated in a double-chamber sachet; one chamber contained lyophilized bacteria, and the other contained buffer. In the first study, 23 U.S. adult volunteers received CVD 103-HgR at 10(8) CFU plus CVD 111 at 10(8), 10(7), or 10(6) CFU, CVD 111 alone at 10(7) CFU, or placebo. In the second study, 275 Peruvian adults were randomized to receive CVD 103-HgR at 10(9) CFU plus CVD 111 at 10(9) or 10(8) CFU, CVD 111 alone at 10(9) CFU, CVD 103-HgR alone at 10(9) CFU, or placebo. Three of 15 U.S. volunteers who received CVD 111 at 10(7) or 10(8) CFU developed mild diarrhea, compared to none of 4 who received CVD 111 at 10(6) CFU and 1 of 4 who received placebo. Twelve (63%) of 19 vaccine recipients shed the El Tor vaccine strain. All but one volunteer developed significant Ogawa and Inaba vibriocidal antibody titers. Volunteers who received CVD 111 at 10(7) CFU had geometric mean Ogawa titers four to five times higher than those of volunteers who received the lower dose. In the second study, all dosage regimens were well tolerated in Peruvians. About 20% of volunteers who received CVD 111 at the high dose excreted the El Tor organism, compared to 7% in the low-dose group. CVD 111 was detected in the stools of two placebo recipients, neither of whom had symptoms or seroconverted. In all vaccine groups, 69 to 76% developed fourfold rises in Inaba vibriocidal antibodies. Among those who received the bivalent vaccine, 53 to 75% also developed significant rises in Ogawa vibriocidal antibodies. We conclude that it is feasible to produce a single-dose, oral bivalent vaccine that is safe and immunogenic against both biotypes (El Tor and classical) and both serotypes (Inaba and Ogawa) of cholera for populations in both developed and developing parts of the world.

Molecular evolution of Vibrio cholerae O1 strains isolated in Lima, Peru, from 1991 to 1995

Following the emergence of cholera in Lima, Peru, in 1991, isolates of Vibrio cholerae O1 biotype El Tor recovered from patients in various parts of Lima were selected and characterized. Ribotyping and pulsed-field gel electrophoresis (PFGE) revealed four BglI ribotypes and eight NotI PFGE types among 50 V. cholerae O1 strains recovered from patients with cholera in Lima from 1991 to 1995, with certain genotypes appearing to cluster geographically. While differences in ribotype and PFGE type patterns suggest that genetic changes are occurring in the strain responsible for the Latin American cholera epidemic, more frequently than previously reported, 40 (80%) O1 strains showed an identical ribotype pattern and 41 (82%) strains showed closely related PFGE types, types 1, 2, or 3, that differed by less than three restriction fragments. All strains were susceptible to nine antibacterial agents studied. In 1991, more than 95% of the clinical V. cholerae O1 strains were serotype Inaba, whereas from 1992, serotype Ogawa began to predominate, with more than 90% of the isolates being of the Ogawa serotype in 1995. The small differences in genotypes of V. cholerae O1 is remarkable because cholera is highly seasonal in coastal areas of Peru and support the hypothesis that the epidemic strain reemerges from an environmental source. However, the relative high rate of genetic changes within V. cholerae O1 as shown by ribotyping and PFGE should be taken into consideration when typing patterns of V. cholerae O1 associated with cholera in Latin America are evaluated.

Field evaluation of rapid HIV serologic tests for screening and confirming HIV-1 infection in Honduras

OBJECTIVE

To determine the ability of simple, rapid tests to identify HIV-1 antibody-positive specimens in field settings using the World Health Organization's (WHO) alternative testing strategies.

DESIGN

Three-phase evaluation of simple, rapid assays using banked specimens and prospectively collected serum specimens at regional hospitals and rural clinics.

METHODS

Seven test (Retrocell, Genie, HIVCHEK, SUDS HIV-1, Testpack, Serodia HIV-1, and HIV-1/2 RTD) were evaluated and results compared with standard enzyme immunoassay (EIA) and Western blot results (phase 1). Further evaluation consisted of prospective testing of routine specimens at regional (phase 2; n = 900) and rural, peripheral laboratories (phase 3; n = 1266) throughout Honduras with selected assays.

RESULTS

Sensitivity and specificity were calculated for each assay and combination of assays for each phase to evaluate the effectiveness of the WHO alternative testing strategies. All tests in all phases were > 99% sensitive after correcting for technical errors, with two exceptions (SUDS, phase 1; HIVCHEK, phase 3). In phase 3, where the testing algorithm was diagnostic, several combinations of assays were 100% sensitive and specific using WHO strategy II or III. For the Honduras Ministry of Health, the combination of Retrocell and Genie was found to be equally sensitive, more specific (no indeterminate results), and less expensive than EIA/Western blot.

CONCLUSION

Combinations of rapid, simple HIV antibody assays provide sensitivity and specificity performance comparable to EIA/Western blot. Application of these combinations in the WHO alternative testing strategies provides an inexpensive and effective method of determining HIV status. Assay combinations using these strategies can be easily performed in small, rural laboratories and have been implemented in routine HIV screening in Honduras.

Isolation of Cry1Ab protein mutants of Bacillus thuringiensis by a highly efficient PCR site-directed mutagenesis system

A site-directed mutagenesis method was designed and used to create Cry1Ab mutant proteins in two of the five highly conserved blocks present in the Cry protein family. Region 1 comprises the central alpha-helix 5 of domain I and has been implicated in the pore formation activity of the toxin. Substitution of arginine by serine at position 173 (R173S) affects neither structural integrity nor toxicity. Region 2 comprises the major part of the domain I/domain II interface, characterized by the presence of numerous hydrogen bonds and electrostatic interactions. Mutations in the salt bridge formed by aspartic acid 242 and arginine 265 (D242N, D242C, R265C, and D242C/R265C) resulted in structurally unstable mutant proteins as is shown by their increased protease sensitivity and lack of biological activity.

Characterization of Vibrio cgolerae non-O1 serogroups obtained from an outbreak of diarrhea in Lima, Peru

In February 1994, an outbreak of diarrhea caused by non-O1 Vibrio cholerae occurred among volunteers in a vaccine trial study area in Lima, Peru. Clinically, 95% of the patients presented with liquid diarrhea with either no or mild dehydration. Serogrouping of 58 isolates recovered from diarrheal patients affected in the outbreak revealed seven different serogroups, with serogroups O10 (21%) and O12 (65%) being predominant. Most of these isolates were susceptible to a variety of antimicrobial agents. None of the 58 isolates hybridized with a DNA probe previously used to detect the gene encoding the heat-stable enterotoxin NAG-ST or produced cholera toxin as assessed by GM1 ganglioside enzyme-linked immunosorbent assay. Ribotyping exhibited 10 different BglI ribotype patterns among the 58 V. cholera non-O1 strains studied. However, ribotyping showed that all isolates belonging to serogroup O12 exhibited identical ribotypes and that 83% of the serogroup O10 isolates belonged to another identical ribotype, thus showing excellent correlation between ribotypes and serogroups. Among a group of O10 and O12 isolates selected for virulence studies, none produced enterotoxin whereas the majority produced a cytotoxin, as assessed in Y1 and HeLa cells. These isolates were also negative for the gene encoding zonula occludens toxin (Zot) as assessed by a PCR assay. The isolates tested showed strong adherence and some degree of invasion in the HEp-2 cell assay, whereas none of the isolates was positive in the PCR assay for the gene encoding the toxin coregulated pilus subunit A antigen (tcpA). In the removable intestinal tie adult rabbit diarrhea model, O10 and O12 serogroup isolates produced severe diarrhea and occasionally death when rabbits were challenged with 10(10) bacterial cells. Fluid accumulation was shown in the rabbit intestinal loop test when whole cultures were injected. No significant difference in virulence was shown between serogroup O10 and O12 isolates. This study provides further evidence that V. chlorae non-O1 non-O139 strains have diarrhegenic potential for humans through a yet-undefined mechanism(s) and that such strains can cause outbreaks.

Immunological response to Vibrio cholerae O1 infection and an oral cholera vaccine among Peruvians

A 'double-blind', randomized, placebo controlled study of an oral inactivated whole cell plus recombinant B subunit (WC/rBS) cholera vaccine was conducted during February-March 1992 in Peru in 346 military recruits, 307 (89%) of whom received 2 oral doses of vaccine or Escherichia coli K12 placebo, 2 weeks apart. Paired serum samples were obtained from 155 (50%) of the recipients of 2 doses. An epidemic of cholera took place between doses. No difference in cholera attack rates was detected between vaccine and placebo recipients after one dose (8% versus 14%). Seroconversion (4-fold or higher increase in vibriocidal antibody titres) was detected in 90% and 80% of vaccine and placebo recipients, respectively, with low pre-existing vibriocidal titres (< 0.01). The anti-cholera toxin seroconversion rate among those with low pre-existing titres was higher in vaccinated subjects (97%) than in placebo recipients (68%) (P < 0.01). Administration of 2 doses of WC/rBS vaccine concomitantly with natural V. cholerae O1 infection enhanced the serum anti-cholera toxin response. The immune response to the whole cell component of the vaccine was reduced by high pre-existing vibriocidal antibody titres.

Immunogenicity in Peruvian volunteers of a booster dose of oral cholera vaccine consisting of whole cells plus recombinant B subunit

Forty-nine subjects received two doses of oral cholera vaccine consisting of whole cells plus recombinant B subunit; this was followed by a booster dose one year later. After the primary series, a significant (greater than twofold) increase in the levels of vibriocidal, anti-cholera toxin immunoglobulin G and anti-cholera toxin immunoglobulin A antibodies occurred in 54, 88, and 81% of the subjects, respectively. Within one year, titers decreased to levels close to baseline. A booster dose then induced rises to those which occurred after the initial vaccination. The results suggest that 1-year booster doses may be necessary to maintain immunity against cholera in Latin America.

Protective efficacy of oral whole-cell/recombinant-B-subunit cholera vaccine in Peruvian military recruits

The cholera epidemic in South America has reinforced the need for safe and effective oral vaccines. In a randomised, double-blind, placebo-controlled efficacy trial among 1563 Peruvian military recruits we have investigated the protective efficacy of an oral inactivated whole-cell/recombinant-B-subunit (WC/rBS) cholera vaccine. Participants were given two oral doses of cholera vaccine or Escherichia coli K12 placebo, with an interval of 7-14 days. 1426 (91%) subjects received the two prescribed doses and were followed up for a mean of 18 weeks (median 21 weeks). After vaccination, Vibrio cholerae O1 El Tor Ogawa was isolated from 17 subjects with diarrhoea. 16 of the cholera cases occurred 2 weeks or longer after the second dose of vaccine (14 placebo recipients, 2 vaccinees). We also detected 14 symptomless infections (11 [7 placebo recipients, 4 vaccinees]) 2 weeks or longer after the second dose. The vaccine had significant protective efficacy against cholera (86% [95% CI 37-97], p < 0.01) but not against symptomless infection (42% [-96 to 85]). All cholera cases were in people of blood group O, who made up 76% of the study population (p < 0.01). Two doses of WC/rBS vaccine, given 1 to 2 weeks apart, provide rapid, short-term protection against symptomatic cholera in adult South Americans, who are predominantly of blood group O. Long-term efficacy studies in Peruvian adults and children are under way.

Diarrheal disease in Peru after the introduction of cholera

Surveillance was conducted one day each week from December 1992 through May 1993 to determine the clinical features and etiology of diarrhea among a population in a suburban community of Lima, Peru. Patients who had had three or more loose stools during the previous 24 hr were enrolled at a clinic located in the community or at a nearby regional hospital. A total of 143 cases of diarrhea were detected for an overall rate of 7.1 cases per 1,000 population. The enteropathogens isolated were Vibrio cholerae 01 (31%), enterotoxigenic Escherichia coli (22%), and Salmonella, Shigella, Campylobacter, and Aeromonas species (10%). Specimens from the remaining cases were negative for enteropathogens. All isolates of V. cholerae were susceptible to tetracycline, doxycycline, nalidixic acid, norfloxacin, trimethoprim-sulfamethoxazole, trimethoprim, gentamicin, chloramphenicol, and cephalothin. Cases of diarrhea associated with V. cholerae were more common among adults, and more likely to experience severe dehydration and require hospitalization than the non-cholera cases. Data indicated that among the cases diagnosed, V. cholerae and enterotoxigenic E. coli were the more common causes of diarrhea in a suburban community of Lima during the summer season.

Phenotype of a Rhizobium leguminosarum ntrC mutant

A Tn5 insertion mutant, strain CFN2012, of Rhizobium leguminosarum biovar phaseoli devoid of glutamine synthetase II (GSII) activity was analysed. It was shown to contain Tn5 within an 11-kb BamHI DNA fragment, which was isolated (pSM261) from the wild-type strain and, when introduced into strain CFN2012, was shown to complement the absence of GSII activity. The DNA sequence of the corresponding region from the wild-type allele revealed the presence of an ntrC regulatory gene, and restriction analysis indicated that the mutant allele carried the Tn5 insertion within it. Further analysis of strain CFN2012 indicated that this mutant has reduced levels of the PII regulatory protein and that, in contrast to ntrC mutants of other Rhizobiaceae, it grows on nitrate as the sole nitrogen source.

The Rhizobium leguminosarum biovar phaseoli glnT gene, encoding glutamine synthetase III

Plasmid pGE203 contains the Rhizobium leguminosarum biovar phaseoli glnT locus. Glutamine synthetase III (GSIII) was purified from a glutamine auxotrophic strain of Klebsiella pneumoniae carrying this plasmid. Sequencing of a 2.4-kb fragment containing the glnT locus reveals an open reading frame of 435 amino acids (aa), whose first eight aa are identical to those determined from pure GSIII by direct aa sequencing, thus confirming that glnT indeed codes for GSIII activity. The comparison of the GSIII aa sequence with the reported sequence of GSs from other organisms shows a significant degree of homology. Since the three-dimensional structure of GS from Salmonella typhimurium is known, a three-dimensional model of GSIII was built by homology.

A previously unrecognized glutamine synthetase expressed in Klebsiella pneumoniae from the glnT locus of Rhizobium leguminosarum

Using glnT DNA of Rhizobium meliloti as a hybridization probe we identified a R. leguminosarum biovar phaseoli (R. l. phaseoli) locus (glnT) expressing a glutamine synthetase activity in Klebsiella pneumoniae. A 2.2 kb DNA fragment from R. l. phaseoli was cloned to give plasmid pMW5a, which shows interspecific complementation of a K. pneumoniae glnA mutant. The cloned sequence did not show cross-hybridization to glnA or glnII, the genes coding for two glutamine synthetase isozymes of Rhizobium spp. While in previous reports on glnT of R. meliloti and Agrobacterium tumefaciens no glutamine synthetase activity was detected, we do find activity with the glnT locus of R. l. phaseoli. The glutamine synthetase (GSIII) activity expressed in a K. pneumoniae glnA strain from pMW5a shows a ratio of biosynthetic to transferase activity 10(3)-fold higher than that observed for GSI or GSII. GSIII is similar in molecular weight and heat stability to GSI.

Taenia solium: cell reactions to the larva (Cysticercus cellulosae) in naturally parasitized, immunized hogs

In hogs naturally infected with Taenia solium larvae (i.e., Cysticercus cellulosae), we studied the host response induced by antigens obtained from the larvae. Histopathological studies of cysticerci removed after 4 and 8 weeks of immunization showed an intense inflammatory reaction surrounding the larvae. The response was greater in the 8-week specimens. A dense layer of eosinophils was in close contact with the external membrane of the bladder wall and, in several cases, the eosinophils had infiltrated this tegument. Many eosinophils were seen in the spiral canal of larvae. This infiltration by eosinophils increased with time. Preparations from the 8-week samples showed many degenerated and disrupted eosinophils whose granules were found in close contact with the outer membrane of the larval tegument and, in some cases, had entered through the broken surface of this structure. More than 90% of the larvae were found in various stages of degeneration; the rest were completely destroyed and surrounded by a mass of eosinophils. After immunization, peripheral blood eosinophilia increased to 17%, whereas the eosinophilia of the control hog was 4% throughout the study. The larval worms removed from control hogs showed intact structures, with a low degree of infiltration by eosinophils and a discrete inflammatory reaction surrounding the bladder wall of the larvae.

Taenia solium: immunity in hogs to the Cysticercus

Protection was induced in hogs against Taenia solium cysticercosis using an immunogenic complex obtained from its larval "bladder worm" form, Cysticercus cellulosae. Immunoelectrophoresis revealed that this complex contained at least eight antigens. In immunized hogs a total of 71 (mean 11.8) cysticerci were found, whereas in the control animals 397 (mean 74.9) were found. Histopathological studies showed that more than 40% of larvae obtained from immunized hogs were completely destroyed and the others were seen in various stages of degeneration. Eosinophils and mononuclear cells were observed infiltrating the internal structures of the larvae. Intense granulomatous reactions of eosinophils, lymphocytes, macrophages, epithelioid cells, plasma cells, and fibroblasts surrounded the larvae. Larvae from control hogs were intact and surrounded by a small inflammatory reaction. The cellular response was measured by the macrophage migration inhibition test, which was higher in immunized hogs when compared with control animals, either before the infection with T. solium eggs or before slaughter. No significant difference was found in the humoral response of immunized and control hogs.